August 19, 1998

SAMPLE INSURANCE CO
C/O SAMPLE INSURANCE CO
%W C DIVISION
204 E WASHINGTON #161
MADISON WI 53720

WC CLAIM NO: 9999-999999
INJURY DATE: 03/30/86
EMPLOYE: SIMPLE, SAMPLE
EMPLOYER: SIMPLE SAMPLE EMPLOYER
INSURER NO:

 According to the employe, the average weekly wage for computing temporary disability payments may be wrong because premium pay or wages at time-and-a-half were not included. For us to verify the correct average weekly wage, please answer the following questions and return this form to the Worker’s Compensation Division within 30 days.

In the 13-week period prior to the date of injury, was the employe paid premium pay or time-and-a-half pay? _____Yes ______No

If ‘yes,’ after how many hours? _________

Was the company’s or department’s work schedule for the employment at which the employe worked at the time of injury in effect for 13 or more weeks prior to the date of injury? ________Yes __________No

If you do not reply to this letter within 30 days, we will set the average weekly wage using time-and-a-half wages or premium pay as submitted by the employe. Thank you for your help in assuring correct compensation payments.

Wage Analyst
(608) 266-3264

WC45K

(R. 3/5/98)